Dr. Ivar Lovaas is the UCLA scientist who developed a treatmentsometimes labeled ABA-DTT. Dr. Lovaas has written this report to answer avariety of questions and mistaken assertions about his work. This is thethird of six installments in the series. To read the first installment, go to: http://www.feat.org/lovaas/intro.htm For the second installment: http://www.feat.org/lovaas/body.htm

In this installment, Dr. Lovaas addresses:

* Are the claims made of certain treatment aspects ignored? * Is the treatment cost-effective? * Are parents satisfied with intensive behavioral treatment? * Does the UCLA project focus on stimulus control and functionalanalysis * Quality Control on Treatment. * Additional Misunderstandings * How valid are the testimonies at Fair Hearings?

The complete report, with references, will be made available on theFEAT website at the conclusion of the series.

CLARIFYING COMMENTS ON THE UCLA YOUNG AUTISM PROJECTIvar Lovaas, Ph.D. August 2, 2000

J. Are the claims made of certain treatment aspects ignored? (1) Children become dependent and do not acquire concepts. Parentswho have sought consultation about UCLA from TEACCH staff have been warnedthat trying to meld the two programs (UCLA and TEACCH) may result in greatconfusion...and considerable anxiety...for the autistic child, and thattheUCLA program promotes dependence...focusing mainly on compliance training,and does not help the children to understand concepts." TEACCH furtherclaims that "operant conditioning programs are very effective with mentallyretarded persons, but such procedures are not as effective with autisticpersons (Mesibov, 1993). Greenspan (1992) presented behavioral schoolsofthought as an example of a common unhelpful approach that ignores thedelayed childs many needs and would result in disorder patterns tobecomestereotyped and more perseverative as (the children) grow (p. 5). There are no data to support these claims. In contrast, there isabundant evidence that behavioral treatment can help autistic childrenacquire complex behaviors such as language and social interaction(Schreibman, 1988). TEACCH apparently assumes that children diagnosed withautism suffer from a life-long disability and, accordingly, has designedtreatment programs which involve the students enrollment in specialeducation throughout their educational career. Outcome data from TEACCHareconsistent with this pessimistic inference (Lord & Schopler, 1989).However, as mentioned earlier, McEachin, Smith, & Lovaas (1993) follow-updata show major and lasting improvements in the language, emotional, andsocial behavior of children diagnosed with autism when treated withintensive behavioral intervention(2) Investigators from UCLA-NPI and TEACCH have suggested that whileintensive behavioral treatment may raise intellectual functioning, it doesnot foster independence. A direct comparison of independence as assessedbya measure called the Vineland Adaptive Behavior Scales exists and can beused to address this claim. The UCLA YAP data were collected on allintensively treated children at an average age of 13 years (McEachin et al.1993). The UCLA-NPI (Neuropsychiatric Institute) data were collected onchildren originally seen at age 2-3 when these children had reached anaverage age of 15 (Freeman et al. 1991). The TEACCH data were collectedonly on high functioning autistic children at an average age of 14 years(Venter et al. 1992). The means at UCLA, UCLA-NPI, and TEACCH, expressedasstandard scores, were as follows:

As can be seen, intensively treated children from UCLA YAP appear tofunction substantially more independently in all areas when compared tochildren from UCLA-NPI or TEACCH. (Greenspan has yet to publish treatmentoutcome data in a peer-reviewed journal). (3) In his review of Social and Behavioral Interventions from theprestigious NICHD conference (Autism 1995: NIH-State-of-the-Science),McIlvane (1996) appears to make the same mistake as Gresham and MacMillan(1997, see below) when he states that flexible behavior over time are moremeaningful than changes in measurements such as IQ. Assignment to regularclasses as the criterion for successful outcome is often meaninglessbecauseit reflects local political and legal mandates more than individual childneed or status. As in other domains of intervention research, studies areneeded to determine the long-term effects of all interventions(particularlyearly intervention) (p. 148). It is difficult to understand the purposeofmaking such statements when the author was familiar with the McEachin,Smith, & Lovaas (1993) outcome data from the UCLA project. (4) Gresham and MacMillan (1997) argued that the intensivetreatment group and the control group differed in terms of the amount ofattention they received, and that the children could have improved becauseof therapist characteristics such as warmth and encouragement. There is nodata to support that attention and warmth by adults facilitates theimprovement of children with autism. Although Bettelheim based histreatment on this faulty notion. (5) These authors further imply that the increase in IQ scores wasnot due to cognitive gains, but rather due to changes in the childsabilityto show what they already know (p. 190). We know of no data-based researchsupporting this assertion but we are familiar with many studies refuting it(reviewed by Rutter, 1983). (6) Gresham and MacMillan (1997) also claim that subjects werepost-tested with different measures than they received at pretest,therebymaking the results of these different testings uninterpretable (p. 189).Do Gresham and MacMillan suggest that one should give a three year old thesame tests as a thirteen year old? They refer to the Bristol et al. (1966)NIH criteria for treatment outcome research to discredit our research andadd some concerns of their own as follows: 1. The UCLA project is based, in part, on principles of operantlearning, however the primary teaching method relies on discrete trialdiscrimination learning and compliance with simple commands (p. 6).Answer: Discrete trials and discrimination learning is not separate fromoperant learning but an integral part of such learning. Furthermore,compliance was not a primary teaching method in the UCLA treatment method.These misunderstandings on the part of Gresham and MacMillan reflect theirlack of knowledge about the treatment employed. 2. Gresham and MacMillans states: We do, however, fault him(Lovaas) for failing to randomly assign subjects to treatments.(p. 11).Answer: An account of why we refrained from using a matched pair randomassignment was provided earlier (see Section B). Matched pair randomassignment is considered an ideal method for assignment, but with a smallnumber of subjects (e.g. 19 in each group) the assignment could well end upwith an unequal distribution (Kazdin,1980). Evidence for randomassignmentin the UCLA project is based on similarity between Control Group I andexperimental group at intake (similar scores on 19 of 20 pretreatmentvariables). Nevertheless, it is possible that some variable, not yetidentified as predictive of outcome, could have been unequally distributed,a problem which faces all investigators. If a parent of an autistic child was to be informed that their childwould be assigned to a no-treatment control group, the parents very likelywould not participate. Instead they would hire their own behavioraltherapists. Anyone attempting to use a matched pair random assignment inautism today would not be able to do so including Gresham and MacMillan,when and if they themselves decide to engage in treatment and treatmentoutcome research. Difficulties encountered by patients in accepting randomassignment to either experimental treatment or standard procedures is aproblem in medical research as well. There are numerous alternatives, suchas the use of wait-list controls, multiple baseline designs, comparisongroups, etc. 3. We do fault him (i.e. Lovaas) for failing to employ measuresthat tapped more discrete behaviors (morethan global IQ and educationalplacement) (p.11). Answer: Gresham and MacMillan were aware of theMcEachin et al. (1993) follow-up which assessed the subjects on manydimensions relevant to autism (see Section D). McEachins Ph.D. thesis,which formed the basis for the 1993 publication was also referenced in the1987 study. Why they chose to ignore data from these publications canperhaps only be answered by Gresham and MacMillan. 4. Pretest scores were optimized by reinforcing compliantbehavior during testing and did not describe how this compliant behaviorwas reinforced. By doing so they violated standardized testadministration procedures (p.8). Answer: We did describe the procedureused during pre-testing, which were consistent with those developed byFreeman (1976). The intent of Freemans procedure is to obtain a morevalidassessment of the childs intellectual potential when non-compliance isreduced. In effect, we biased outcome against us by using Freemansprocedure, not using that procedure is likely to have resulted in lowerintake IQ scores and a larger increase in IQ scores at follow-up. 5. Social class of the children was not measured (which would)restrict the extent to which one can generalize findings (p. 10). Answer:We did measure family characteristics [( number of siblings in the family(1.26 in each group), socioeconomic status of the father (Level 49 vs.Level54 according to 1950 Bureau of the Census standards,) boys to girls (16:3vs. 11:8)] Lovaas (1987) (p.6). (See also Section C). 6. (Control 2 subjects were not treated by (the Young Project)but were receiving some unspecified form of treatment (p. 6). Answer:Control group II subjects received services which are commonly available toautistic children in the community, special education and speech therapy.The poor outcome in this group is consistent with outcome data from otherinvestigations of such services. 7. Smith and Lovaas are unwilling to concede any limitations onwhich the effectiveness of (the Young Autism Project) resides Whatexplains this apparent refusal to admit to a single limitation in theseinvestigations? (p. 10). Answer: We have identified limitations andcautions both in regard to outcome data and treatment integrity. Already30years ago Lovaas presented an invited address to parents and professionalson Strengths and Weaknesses of Operant Conditioning Techniques for theTreatment of Autism (Top Priorities for Mentally Ill Children. 2ndAnnualmeeting and Conference of the National Society for Autistic Children. June24-27, 1970, (30-41) San Francisco). In the Lovaas 1987 report we warnthata number of measurement problems remain to be solved (p.8) and illustratethis by describing difficulty in measuring play behavior, communicativeplayand IQ scores. We warned that the term normal functioning raisesquestionsabout whether these children truly recovered from autism (p.8) Othercautions about the 1987 follow-up were reviewed in Sections I to III. Wealso expressed caution about therapist requirements (extensivetheoreticaland supervised practical experience in one-on-one behavioral treatment(p.8). Many treatment variables are left unexplored, such as effect ofnormalpeers (p.8). Mention is made of the limitations .on generalization ofour data to older autistic children (p.8). McEachin et al. (1993)repeatedthe need for replication: The most important void for research to fill atthis time is replication by independent investigators (p. 370) andrepeatedthe extensive training requirements on therapists. We then go on todescribe another void, namely to better serve the children who did notachieve normal functioning, suggesting that perhaps such children requirenew and different interventions that have yet to be discovered (p. 370).Does this sound like a refusal to admit to a single limitation as Greshamand MacMillan have expressed? 8. Greshman and MacMillan do also cite Schopler et al. (1989) to theeffect that our subjects were clearly not representative of all childrenwith autism (p. 9). Answer: In Section A we provided data indicating howdata from Schoplers (1989) sample was not representative and misleading.We also presented our data (on diagnosis, child characteristics, etc.)supporting our claim that the samples used in the Lovaas (1987) study werein fact representative of children with autism. Gresham and MacMillan didalso fail to indicate the inclusion of Control Group II in helping insurerepresentativeness of the Lovaas (1987) sample. Instead, Gresham andMacMillan (1997) statesit is unclear why this group was included in thedesign other than because it represented a conveniently available, patchedup control group (p. 187). Answer: The use of Control Group II wasexplicitly described to help insure that .the referral process did notfavor the project cases because there were no significant differencesbetween Control Group I and II at intake or follow-up, even though ControlGroup II subjects were referred to others by the same agency (p. 7).Furthermore, the poor outcome in the similarly constituted Control GroupIand II would seem to eliminate spontaneous recovery as a contributingfactorto the favorable outcome in the experimental group (p. 8). Gresham andMacMillan refer to both studies. Why they have chosen to ignore these datacan perhaps best be answered by them. Although it may seem to be reasonable to specify whether the samplesare representative of other clients diagnosed with autism, the value ofsuchan undertaking depends on the usefulness of the diagnosis of autism inresearch and treatment. There seems to be some consensus building thatthere are many causes of autism, hence there are likely to be many anddifferent kinds of autism, requiring different kinds of treatment andpreventive measures. This is analogous to what is happening in cancerresearch where many kinds of cancers have been identified with differentcauses requiring different treatments and yielding different outcomes. Intreatment research, the definition of different kinds of autism can best bedetermined by identification of different kinds of causes and treatmentoutcomes, that is, based on a functional analysis rather than thetraditional identification based on communality in the appearance of thebehavioral topographies. This also holds, not just in the case for thebehavioral grouping called autism, but for the separate behaviors involvedin that grouping. For example, self-injurious behavior enjoy threedifferent kinds of determinants, positive, negative or sensoryreinforcementwhich varies across clients. The treatment for each is different so that aparticular kind of treatment (e.g. contingent social isolation) willdecrease one kind of self injury, increase another, and leave a third kindof self-injury unaltered. What is required for the effective treatment ofself-injurious behaviors is a functional analysis (a cause-effect analysis)of the particular kind of self-injurious behavior confronting thepractitioner.

Kanners diagnosis of these children is based on behaviors of similarphysical appearances. That is, behaviors like mutism, echolalia, socialisolation, emotional aloofness, rituals and self-injury, low scores on IQtests, etc. may look similar to the observer. However, as stated above,similar looking behaviors may have different causes and therefore may notbelong together, i.e. respond in a similar way to the same intervention.What is often forgotten in traditional autism research is the fact that thediagnosis of autism is an hypothesis. That is, the diagnosis is based on aguess that there exist an underlying organizing force tying the behaviors(symptoms) together. Kanners diagnosis has shown itself to be a poorhypothesis, given that, in the 55 years after Kanner proposed thediagnosis,no cause or treatment for autism has been found. The most effectivetreatment addresses the problems of these children on a behavior bybehaviorbasis and there is little evidence of generalization of treatment effectsacross behaviors. Although searching for the cause of and treatment forautism may seem like a noble effort, Kanners hypothesis may well bemisleading and delaying the discovery of effective treatments for thesechildren. The sooner the hypothesis is rejected, the more productive ofcauses and treatments our search may be. See also Hacking (1999, p.112-115) description of autism (and schizophrenia) as socialconstructionsand problems associated with large-scale public acceptance of suchconstructs. 9. The added benefit of the Lovaas program, given the high cost,should be examined (p. 12). The precious economic resources foreducation (p. 12) is sited as a reason to be concerned about cost oftreatment. Answer: An approximation to the substantial savings involvedinimplementing behavioral treatment has been provided later in this paper(Section K). The treatment of children with autism has cost a great deal of moneyin other ways as well. In D.B. v. Greenwich, Frank Gresham testified forone day as an expert witness to defend Greenwich, Connecticuts 10 hoursper week ABA program. Expert witnesses such as Gresham are able to chargelarge fees for their services. Ultimately, Gresham admitted under oaththatthe Districts per hour presentation of ABA programs was only 1/4 of thefrequency which Dr. Gresham considered to be appropriate. In California, Gresham testified on behalf of another district in aneffort to defeat a child seeking reimbursement for a forty hour per weekprogram. The district lost and the hearing officer held that a 40 hour perweek ABA program was precisely what the child needed. To date, Gresham hasonly testified on behalf of school districts and apparently has never beeninvolved with any district which has prevailed.

In May of 1999, in T.H v. Palatine, a federal district inIllinois, after a protracted two-year court battle, held that a schooldistricts offer of services in a multiple-handicap class was absurd anddirected the district to pay for the childs home-based ABA program, aswellas the familys attorneys fees. Significantly, the family had offered tosettle the entire dispute at the outset for only $18,000. Ultimately, thisdistrict was compelled to pay out more than $300,000, including the schooldistricts own attorneys fees. We are in full agreement with Gresham and MacMillans concerns about families receiving services from therapists who havereceived less than optimal training and less supervision in deliveringearlyand intensive behavioral intervention. Earlier in this paper (see SectionE) we described the training requirements for sites involved in thereplication project. It is of major concern to us to learn of providerswhopresent themselves as competent in providing the UCLA model and may sitetheUCLA follow-up studies as support for their treatments. Except for staffatthe replication sites, we know of no providers who have been recentlytrained in the UCLA model and sought to be updated. Without updatingtreatment quality is likely to suffer (Wolf et al. 1995). Also, few if anyprovide clinic-based treatment as in the Lovaas (1997) report, but rely onworkshop-based treatments where the family hires staff to be trained in oneto three days of workshops, with supervision one to three month apart.Hardly any provide outcome data. We estimate that outcome data documenting normal functioning fromsuchservices will be less than 10 percent. This does not imply that thechildrenwill fail to make improvements. Behavioral interventions (as in AppliedBehavior Analysis) is based on thousands of scientific papers in Learningand Behavior reported in peer-reviewed journals over more than a hundredyears. There are ample data supporting the effectiveness of behavioraltreatments addressing self-help skills, reduction in self-injury, communityfunctioning, peer-play, school adjustment, language development, and soforth, all of which should help the child become both more competent andself-sufficient. The problem is that, for children who fail to reach normalfunctioning and fail to become integrated and learn from typical peers,services need to continue, for example by the parents efforts. If not theclient will regress, showing little if any benefit from earlier treatmentaswas demonstrated in the Lovaas et al. (1973) outcome study. We are alsoseriously concerned about efforts (some of which are supported by federalgrants) to compare the UCLA Young Autism Project against alternate forms oftreatment, using staff who have not been trained in UCLA procedures andhaveyet to demonstrate quality control on treatment. These problems are alsodiscussed below (in Section V). There are many issues involved here. One important issue is centeredon the failure of alternate treatments to document effectiveness on normedtests in peer-reviewed journals. This includes services such as specialeducation, speech therapy, sensory motor training, floor-time, optionmethod, psycho-dynamic therapy, holding therapy, gentle teaching, etc.Parents win support in Fair Hearings, not because the behavioral treatmenttheir children receive answers all or most problems. Rather, behavioraltreatment can demonstrate, in an objective data-based manner, that theirchildren have made improvements when other services fail to do so. The lawis rational, and by that is meant that it is data-based. One fortunateconsequence of Fair Hearings may be to stimulate research on treatments forautistic children and to report, at an early date and in peer-reviewedjournals, whether such treatments and treatment combinations are effectiveor not. If not effective, the treatment should not be offered and /orwarnings about their potential ineffectiveness and/or harm should be postedas is required in medicine. If not we will continue to mislead parents andwaste childrens lives.

A major and welcomed step ahead would be for Special Education totakeadvantage of what is known in behavioral treatments. Behaviorists aredelivering a form of special education, the earliest efforts beingrepresented in the work of Itard (1932) some 200 years ago. Itard,considered the father of special education, gave impetus to the work ofpersons like Montessori, Sullivan, Kephart and Fernald. Anyone who readsItards descriptions of his treatments will recognize their similarity tobehavioral ones. Itards treatments did not survive and ended up goingnowhere (except perhaps in the use of sensory integration) because Itarddidnot know how to objectively document treatment outcomes. Let us not oncemore make that mistake.

K. Is the treatment cost-effective? The price of treatment is often mentioned as a reason for not fundingforty hours per week of one-on-one intervention. The cost is estimated at$60,000 per year, or $120,000 for the average of two years required fornormal functioning at which point the best-outcome children no longerrequire further special services. This contrasts to the cost of more than$2,000,000 dollars of life-long protective care. Regarding expense, 77% ofthe children in the UCLA-NPI study were inpatients at the hospital. Theaverage stay at UCLA-NPI was about a month at a cost of approximately $1000per day. These children then attended special education classes which haveyet to document their effectiveness. The children are expected to needlife-long protective care. At TEACCH, the costs per year are lower(estimated by Lord and Schopler in a 1994 article as $1200 per year).However, the children continued to be enrolled at the completion ofTEACCH'sstudy, and the expectation seems to be that they will be enrolledthroughouttheir lives. For a more detailed analysis of the cost-effectiveness ofbehavioral intervention, see Jacobson, Mulick and Green (1998).

L. Are parents satisfied with intensive behavioral treatment? The UCLA project has been accused of being stressful for parents. Ourdata show otherwise. On a 7-point rating scale (7 being "completelysatisfied") the UCLA project received a mean rating from parents of 6.9 forclients served since 1991. On a different survey, data from 140 parents whorated UCLA workshops on a 5-point scale across six dimensions (from "Wastherapist polite and sensitive to parent's needs?" to "Would you recommendasimilar workshop to others?") show ratings to be 4.9, 4.9, 4.8, 4.9, 4.5,4.9 (4.5 on the question "How effectively do you think you can nowimplementbehavioral techniques?").